Healthcare Provider Details

I. General information

NPI: 1205106523
Provider Name (Legal Business Name): JOHN ROBERT WYATT JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2012
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W KINGSHIGHWAY
PARAGOULD AR
72450
US

IV. Provider business mailing address

3 LUKAS CV
PARAGOULD AR
72450-7567
US

V. Phone/Fax

Practice location:
  • Phone: 870-239-7000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR077091
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number2024036785
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number810543
License Number StateMS
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number16514
License Number StateTN
# 5
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberC002963
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: